Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Winchester Terrace during CMS and state inspections, most recent first.
A CNA transferred a resident with significant cognitive and physical impairments using a mechanical lift without the assistance of a second staff member, contrary to the resident's care plan, physician orders, and facility policy, which all required two staff for such transfers.
A resident with severe cognitive impairment and high fall risk was injured when a CNA and RN failed to safely operate a Hoyer lift during a transfer. The staff did not ensure the sling straps were secured and forcefully moved the lift when it became stuck, causing the resident to fall and sustain lacerations requiring medical treatment.
Surveyors identified extensive flooring damage and unsanitary conditions throughout the facility, including raised and buckled laminate, stained and torn carpeting, and exposed subflooring in multiple hallways and common areas. Staff interviews confirmed that flooding from clogged courtyard drains contributed to these issues, and that professional cleaning did not resolve the persistent stains and odors. Facility leadership documented the need for new flooring, but concerns remained unaddressed, impacting all residents.
A resident with severe cognitive impairment and mobility assistance needs was improperly transferred by a CNA without using the required mechanical lift and additional staff assistance. This resulted in the resident falling and sustaining a displaced fracture of the distal humerus. The incident was not immediately reported, and the facility's policy on safe transfers was not followed, leading to the CNA's termination.
A CNA failed to follow infection control procedures during incontinence care for a resident with multiple health issues, including using only two washcloths for cleaning, not washing hands before donning new gloves, and not disinfecting the bedside table. The resident was dependent on staff for personal care and hygiene.
The facility failed to maintain a clean and safe environment, affecting all 44 residents. Observations revealed stained and peeling carpeting throughout the facility, creating tripping hazards. The Administrator confirmed the condition and mentioned budget constraints for replacement. Additionally, the dining room sink had significant discoloration and sludge, which was verified by the Administrator.
The facility failed to provide complete SNF ABN notices to two residents, affecting their understanding of the discontinuation of skilled therapy services. The notices lacked specific details about which services were ending and the costs involved if the residents chose to continue these services. An interview with the Administrator confirmed these deficiencies.
A resident dependent on staff for ADLs, including hygiene tasks, was not provided assistance with shaving despite expressing a preference to be clean-shaven. The resident's family confirmed the preference, and shaving supplies were available, but staff failed to offer assistance. Interviews with LPN and STNA revealed a lack of awareness and reminders needed for completing such tasks, leading to the deficiency.
The facility failed to provide a program of activities that met the needs and preferences of its residents, affecting three residents. One resident, receiving hospice care, had no documented activities by staff despite a care plan for engagement. Another resident, with physical impairments, reported not participating in activities due to their physical demands, and a third resident noted a lack of activities during evenings and weekends. The Activity Director confirmed these deficiencies, citing budget constraints and staffing limitations.
The facility failed to ensure that urinary catheter bags for two residents were not resting on the floor, as observed during a survey. One resident with a suprapubic catheter and another with an indwelling urinary catheter were found with their catheter bags on the floor, contrary to their care plans and infection control policies. This was confirmed by nursing staff.
The facility did not ensure that the results of complaint investigations by the state survey agency were available as required, affecting all 44 residents. The survey results binder in the main lobby contained only the last annual survey report, missing four complaint investigation results since then. The DON confirmed the binder should include both annual and complaint investigation results and needed updating.
The facility failed to notify the LTC Ombudsman about resident transfers to the hospital, affecting 12 residents and potentially impacting all 44 residents in the facility. A review of records from April to July 2024 showed multiple hospital discharges without the required notification. The Administrator confirmed the oversight, acknowledging that the notification process had been neglected.
Mechanical Lift Transfer Conducted Without Required Second Staff Member
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) transferred a resident using a mechanical lift without the required assistance of a second staff member. The resident involved had diagnoses including normal pressure hydrocephalus, hemiplegia, and dementia, and was cognitively impaired, requiring total staff assistance for activities of daily living. The resident's care plan and physician orders specified the use of a mechanical lift with two staff members for all transfers. Observation revealed that the CNA entered and exited the resident's room with the mechanical lift alone, and later confirmed in an interview that she performed the transfer without a second staff member present, despite being trained and aware of the policy. Review of the facility's policy also confirmed that two staff members are required for mechanical lift transfers. This incident was discovered during a complaint investigation.
Improper Hoyer Lift Use Results in Resident Fall and Injury
Penalty
Summary
Staff failed to operate a Hoyer lift in a safe manner during a transfer, resulting in a resident falling and sustaining injuries. The incident occurred when a CNA and an RN attempted to transfer a resident with severe cognitive impairment and total dependence for transfers using a Hoyer lift. During the process, the lift became stuck, and staff forcefully pulled and pushed the equipment, leading to the disconnection of the transfer sling strap and causing the resident to fall to the floor. The resident involved had a history of chronic kidney disease, hypertensive heart disease, and venous insufficiency, and was identified as high risk for falls, requiring the use of assistive devices for transfers. The care plan specified the use of a Hoyer lift and staff assistance for all transfers. Despite these interventions, the staff did not ensure that the sling straps were properly secured before attempting the transfer, and did not follow safe transfer procedures when the lift became jammed. As a result of the fall, the resident sustained a laceration above the right eyebrow that required sutures and a laceration to the right wrist that required wound care. Staff statements and medical records confirmed that the improper handling of the Hoyer lift and failure to secure the sling straps directly led to the resident's injuries.
Widespread Flooring Damage and Unsanitary Conditions Identified
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment, as evidenced by multiple observations of damaged and unsanitary flooring throughout the building. Surveyors observed raised and buckled laminate flooring at the courtyard entrance, as well as widespread discoloration, stains, tears, and fraying of carpeting in several hallways, including Malabar Lane Hall, Oakhill Hall, Oakhill Circle Hall, [NAME] Court Hall, and [NAME] Avenue Hall. In several locations, the carpet was lifted or torn, exposing the subfloor, and large brown stains and fraying were present in front of multiple residents' rooms and common areas. The flooring issues were confirmed by both the Maintenance Director and the Director of Nursing, who stated that the problems persisted despite professional cleaning and that the carpeting throughout the facility needed replacement. Interviews revealed that the facility experienced flooding due to courtyard drains clogging with mulch during heavy rain, causing water to back up into the building. The Maintenance Director described using equipment to clean and dry the affected areas, and noted that the dining room developed a strong musty odor and had to be closed temporarily. Email correspondence from the DON to the Facility Manager documented ongoing concerns about carpet stains, fraying, rippling, and holes in various areas, with no response from management. Facility policies reviewed required the environment to be safe, clean, comfortable, and homelike, but these standards were not met, affecting all 46 residents in the facility.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the safe transfer of a resident, resulting in an avoidable accident and major injury. Resident #10, who had severe cognitive impairment and required substantial assistance for mobility and transfers, was improperly transferred by CNA #400. Despite the resident's care plan indicating the need for a mechanical lift and assistance from additional staff, CNA #400 attempted to transfer the resident using a walker without additional help. This led to the resident falling backward onto the bed and striking her right elbow on the metal bed frame, causing a displaced fracture of the distal humerus. The incident occurred on 09/08/24, but was not immediately reported by CNA #400, who did not believe the incident resulted in an injury. The resident later complained of pain, and an x-ray confirmed the fracture. The resident was subsequently transferred to the hospital for treatment. The facility's investigation revealed that CNA #400 was aware of the resident's transfer requirements but failed to adhere to them, leading to the injury. The facility's policy on safe transfers and ambulation was not followed, as evidenced by the actions of CNA #400. The CNA's failure to use the mechanical lift and seek assistance from other staff members directly contributed to the resident's injury. The facility's Director of Nursing confirmed the details of the incident and the violation of company policy by CNA #400, who was ultimately terminated for this breach.
Infection Control Deficiency During Incontinence Care
Penalty
Summary
The facility failed to maintain proper infection control measures during incontinence care for a resident. During an observation, a CNA was seen using only two washcloths to clean both the front and back peri-areas of a resident, placing the used washcloths directly on the bedside table without a barrier. The CNA also used a towel to dry the resident and placed it on the bed sheet. After completing the care, the CNA removed soiled linens with a bare hand, did not wash or sanitize hands before donning a new glove, and failed to disinfect the bedside table after use. The resident involved had a history of stroke, high blood pressure, Bell's Palsy, and right-sided weakness, with moderately impaired cognition and was always incontinent of bladder and bowel. The resident was dependent on staff for personal care and hygiene and was receiving hospice services. The facility's Director of Nursing confirmed that the CNA did not follow the expected infection control procedures, which include using multiple washcloths, proper glove use, handwashing, and disinfecting equipment.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain carpeting in a clean, sanitary, and safe condition, which had the potential to affect all 44 residents. Observations made on June 30, 2024, between 8:00 A.M. and 4:00 P.M. revealed numerous large stains and instances of carpet peeling throughout the facility, creating tripping hazards. The Administrator confirmed the condition of the carpeting on July 1, 2024, and mentioned that some areas had been replaced approximately six months ago, but there was no budget for further replacement. Additionally, on July 2, 2024, at 12:00 P.M., the dining room sink was observed to have significant brown and black discoloration in and around the drain. A thick brown layer of sludge was removed with a towel, but the discoloration remained. The Administrator verified the condition of the sink and drain during an interview on the same day.
Incomplete SNF ABN Notices for Therapy Services
Penalty
Summary
The facility failed to provide complete and accurate Skilled Nursing Facility Advanced Beneficiary Notices of Non-coverage (SNF ABN) to two residents, affecting their understanding of the discontinuation of skilled therapy services. Resident #6, admitted with diagnoses including bronchitis, sepsis, and osteoporosis, received an SNF ABN on June 14, 2024, indicating the cessation of skilled therapy services due to reaching maximum benefits. However, the notice lacked specific details about which therapy services were ending and the exact costs the resident would incur if they chose to continue these services. The cost section was ambiguously labeled as 'daily cost,' providing insufficient information for the resident to make an informed decision. Similarly, Resident #8, who was admitted with schizophrenia, sepsis, and morbid obesity, received an SNF ABN on June 26, 2024, with the same deficiencies. The notice did not specify which therapy services were being discontinued or the specific costs associated with continuing these services. An interview with the Administrator on June 30, 2024, confirmed that the SNF ABNs provided to both residents lacked the necessary information regarding the termination of skilled services and potential costs, leading to a deficiency in the facility's compliance with notification requirements.
Failure to Assist Resident with Hygiene Tasks
Penalty
Summary
The facility failed to provide necessary assistance with hygiene tasks for Resident #194, who was dependent on staff for activities of daily living (ADL). Resident #194, diagnosed with malignant neoplasm of the pancreatic duct, type II diabetes mellitus, vertigo, and weakness, was admitted on an unspecified date and required staff assistance for bathing, dressing, and hygiene tasks. Despite the care plan indicating the need for assistance with these tasks, observations and interviews revealed that the resident had unkempt facial hair and expressed a preference to be clean-shaven. The resident's family member confirmed this preference and noted that a personal electric razor was available in the resident's room, yet staff had not offered assistance with shaving. Interviews with staff, including LPN #404 and STNA #412, confirmed that the resident required hands-on assistance with ADLs and that aides should complete hygiene tasks daily, including shaving male residents if preferred. However, STNA #412, who was assigned to care for the resident, was unaware of the resident's shaving preferences and did not offer assistance despite noticing shaving supplies in the room. The Director of Nursing (DON) also observed the resident's unchanged facial hair and described the resident as scruffy, acknowledging the need to offer shaving assistance. The facility's policy emphasized person-centered care, yet the failure to adhere to this policy resulted in the deficiency.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide a program of activities that met the needs and preferences of its residents, affecting three residents. Resident #41, who had severe cognitive impairment and was receiving hospice care, had a care plan that included engaging in simple, structured activities. However, the resident's activity documentation showed only five entries of family/friend visits over a month, with no recorded activities by the activity staff. The Activity Director admitted to not having spoken to the family to understand the resident's preferences and confirmed no documentation of activities or attempts for Resident #41 in the past 30 days. Resident #3, who was cognitively intact but had impairments in both upper and lower extremities, reported not participating in activities because they required physical abilities she did not possess. The resident's record showed no activity documentation for the past 30 days. The Activity Director confirmed the lack of documentation and acknowledged that some activities, like the monthly happy hour, were canceled due to budget constraints. Resident #8, who had intact cognition and enjoyed activities like BINGO and crafting, also had no activity documentation for the past 30 days. The resident reported a lack of activities during evenings and weekends, as the Activity Director worked only weekdays. The Activity Director confirmed the absence of evening activities and stated that STNAs were expected to handle weekend activities, although there was no designated activity personnel for weekends. The facility's policy emphasized the importance of person-centered care and supporting residents' preferences, which was not reflected in the activity program provided.
Failure to Maintain Proper Positioning of Urinary Catheter Bags
Penalty
Summary
The facility failed to ensure that urinary catheter bags for two residents were not resting on the floor, as observed during a survey. Resident #28, who has a suprapubic catheter due to obstructive and reflux uropathy, was found with her catheter bag hung on a trash can and resting on the floor. This was confirmed by a registered nurse who noted that the catheter tubing was caught in the footrest of the recliner the resident was sitting in. The resident's care plan included an intervention to prevent the urinary drainage bag from lying on the floor, which was not adhered to. Similarly, Resident #20, who has an indwelling urinary catheter due to neuromuscular dysfunction of the bladder and chronic kidney disease, was observed with the catheter bag resting on the floor. This observation was confirmed by an agency licensed practical nurse. The resident's care plan also included an intervention to prevent the urinary drainage bag from lying on the floor, which was not followed. The facility's infection prevention and control policy, as well as CDC guidelines, emphasize the importance of keeping catheter bags off the floor to prevent infections.
Failure to Update Survey Results Binder
Penalty
Summary
The facility failed to ensure that the results of complaint investigations conducted by the state survey agency were available as required, potentially affecting all 44 residents residing in the facility. An observation in the facility's main lobby area revealed a white binder intended to contain state survey results, but the most recent report in the binder was dated 04/23/23. A review of the facility's previous survey activity showed that the Ohio Department of Health conducted complaint investigation surveys on 11/03/23, 12/19/23, 02/07/24, and 04/09/24, but the results of these surveys were not present in the survey book at the time of the observation on 06/30/24. An interview with the Director of Nursing (DON) confirmed that the survey results binder contained only the results of the last annual survey and was missing the four complaint investigation results reports since the last annual survey. The DON acknowledged that the survey results book should include both annual and complaint investigation results and stated that the book needed to be updated.
Failure to Notify LTC Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to notify a representative of the Office of the State Long-Term Care Ombudsman about resident transfers to the hospital, affecting 12 residents reviewed for hospitalization and transfers. This oversight had the potential to impact all 44 residents currently residing in the facility. The deficiency was identified through a review of admission transfers and discharges from April 2024 through July 2024, which revealed that multiple residents were discharged to acute care hospitals without the required notification to the LTC Ombudsman. The medical records of the affected residents showed no evidence that the LTC Ombudsman was informed of their hospital transfers. An interview with the facility's Administrator confirmed that the notification process had been neglected, acknowledging that the responsibility to notify the LTC Ombudsman had unfortunately 'fallen through the cracks.' This lack of notification represents a failure to comply with the regulatory requirement to inform the Ombudsman of resident transfers, thereby constituting a deficiency in the facility's operational procedures.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mansfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Liberty Nursing Center Of Mansfield | 0.8 mi | ★★★★★ | 0 | 0 |
| Jag Healthcare Mansfield | 1.6 mi | ★★★★★ | 0 | 0 |
| Crystal Care Center Of Mansfie | 3.8 mi | ★★★★★ | 0 | 0 |
| Arbors At Mifflin | 4.6 mi | ★★★★★ | 0 | 0 |
| Oak Grove Manor | 4.6 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.